Pre-hospital improvised bronchodilator therapy of a patient on bi-level positive airway pressure therapy

On the 15th of June 2011 the Medical Director of the Scottish Ambulance Service approved the use of a T-piece in-line nebulizer device (Figure 1) for use by paramedics and emergency medical technicians (Scottish Ambulance Service, 2011). This internal communication indicated that instruction on its use would follow during mandatory updates and after such training, staff would then be deemed competent and authorised to use this device. Shortly after this directive, a call to attend a forty-year-old male having breathing diffculties was received by the Emergency Medical Dispatch Centre (EMDC) and was subsequently attended by the authors. Both authors had not yet attended the mandatory update referred to above and consequently did not carry the T-piece in-line nebulizer device.

On arrival it was found that the patient had a patent airway supported by a non-invasive ventilation (NIV) device via nasal mask, was breathing at a rate of 30 breaths per minute, had a heart rate of 160 beats per minute with full, regular radial pulses and was alert’ on the AVPU scale (AVPU: Alert, responds to Verbal stimulus, responds to Pain, Unresponsive).